RELATIONSHIP OF POLYPHARMACY AND POLYPATHOLOGY WITH
FALLS AMONG INSTITUTIONALIZED ELDERLY
Karine Marques Costa dos Reis1, Cristine Alves Costa de Jesus2
1 Ph.D. in progress in the Post-graduate Nursing Program of the Universidade de Brasília (UnB). Secretary of Health Nurse of the
Federal District. Health Sciences Professor. Brasília, Federal District, Brazil. E-mail: karinereisdf@hotmail.com
2 Ph.D. in Fundamental Nursing. Professor of the Health Sciences Faculty Nursing Department and the Post-graduate Program
in Nursing of the UnB. Brasília, Federal District, Brazil. E-mail: cristine@unb.br
ABSTRACT
Objective: identify relationships of association between the risk of falls in institutionalized elderly people with polypharmacy and polypathy, as well as to outline the epidemiological proile of its casuistry.
Method: a prospective obseracional study with 271 elderly residents in long-stay institutions in the Federal District (Brazil). The date were a actualized by inferencial statistics.
Results: a monitoring of elderly conirmed the association between polypathology and falls (p: 0.0028), however, it did not follow the trend of other studies in identifying polypharmacy as a risk factor for falls (p: 0.141). Among the most prevalent comorbidities, changes in blood pressure levels (77.4%), followed by Diabetes Mellitus (27.37%), depression (17.7%) and dementia (46.8%) may be highlighted. The most
identiied drugs were antihypertensives (73.8%), sleep inducers (61.2%), diuretics (50.1%) and antidepressants (34.3%).
Conclusion: multiple disabilities associated with chronic-degenerative diseases and the chronic use of medications may interfere with the incidence of falls, ratifying factors related to the diagnosis of risk for falls presented in the NANDA-I Taxonomy I. This contribution to the nurses’ diagnostic rationale ensures better evaluation of the elderly, ensuring a care plan focused on prevention and detection of risk conditions.
DESCRIPTORS: Health of the elderly. Use of medications. Accidental falls. Nursing diagnosis.
RELAÇÃO DA POLIFARMÁCIA E POLIPATOLOGIA COM A QUEDA DE
IDOSOS INSTITUCIONALIZADOS
RESUMO
Objetivo: identiicar relações de associação entre o risco de queda em idosos intitucionalizados com a polifarmácia e a polipatologia, bem como traçar o peril epidemiológico desta casuística.
Método: estudo prospectivo, observacional realizado com 271 idosos moradores de instituições de longa permanência do Distrito Federal. Os dados foram atualizados por estatística inferencial.
Resultados: o acompanhamento dos idosos conirmou a associação entre a polipatologia e a queda (p: 0,0028), porém não seguiu a tendência de outros estudos em identiicar a polifarmácia como fator de risco de queda (p: 0,141). Entre as comorbidades mais prevalentes destacou-se alteração dos níveis tensionais (77,4%), seguida de Diabetes Mellitus (27,37%), depressão (17,7%) e demência (46,8%). Já os medicamentos
mais identiicados foram os anti-hipertensivos (73,8%), indutores do sono (61,2%), diuréticos (50,1%) e antidepressivos (34,3%). Conclusão: que múltiplas incapacidades associado a doenças crônico-degenerativas e o uso crônico de medicamentos, podem interferir na incidência de queda, ratiicando os fatores relacionados ao diagnóstico risco de queda presente na Taxonomia I da NANDA-I. Essa contribuição ao raciocínio diagnóstico do enfermeiro garante melhor avaliação do idoso, garantindo um plano de cuidados voltado a prevenção e detecção de condições de risco.
RELACIÓN DE LA POLIFARMACIA Y POLIPATOLOGÍA CON LA CAÍDA DE
ADULTOS MAYORES INSTITUCIONALIZADOS
RESUMEN
Objetivo: identiicar relaciones de asociación entre riesgo de caída en adultos mayores institucionalizados con la polifarmacia y la polipatología, asi como trazar un peril epidemiológico de esta casuística.
Método: estudio prospectivo, observacional realizado con 271 ancianos residentes de instituciones a largo plazo del Distrito Federal. Los datos han sido actualizados por inferencial.
Resultados: el acompañamiento de adultos mayores conirmó la asociación entre la polipatología y la caída (p: 0,0028), sin embargo no siguió la tendencia de otros estudios en identiicar la polifarmacia como factor de riesgo de caída (p: 0,141). Entre las comorbidades más prevalentes se destacaron la alteración de los niveles tensionales (77,4%), seguida de la Diabetes Mellitus (23, 37%), depresión (17,7%) y
demencia (46,8%). Los medicamentos más identiicados fueron los anti-hipertensivos (73,8%), inductores del sueño (61,2%), diuréticos (50,1%) y antidepresivos (34,3%).
Conclusión: que multiples incapacidades asociado a enfermedades crónico degenerativas y el uso crónico de medicamentos pueden interferir en la incidencia de caída, ratiicando los factores relacionados al diagnóstico de Riesgo de Caída presente en la Taxonomia I de la NANDA-I. Esta contribución al raciocinio diagnostico del enfermero garantiza mejor evaluación del adulto mayor, garantizando un plano de cuidados vinculado a la prevención y detección de condiciones de riesgo.
DESCRIPTORES: Salud del adulto mayor. Uso de medicamentos. Accidentes por caídas. Diagnóstico de enfermería.
INTRODUCTION
Brazil, as well as other developing countries, has been experiencing a signiicant growth of its elderly population. In addition to this demographic transition, an epidemiological transition is also observed alongside the changes in the country’s health proile, where chronic degenerative diseases have replaced the acute infectious-contagious dis-eases characteristic of the 1960s. As a consequence of this transition, the use of drugs by this popu-lation increases every day, and as a result of the higher prevalence of chronic diseases, the elderly are possibly the most medicalized age group in society since their treatment involves the associa-tion of numerous drugs.1-2
In association with the physiology of the elderly whose functional reserve is diminished, the processes of absorption, distribution, metaboliza-tion and eliminametaboliza-tion of drugs are differentiated, leading to adverse reactions related to their use. In this context, falls are considered a syndrome due to innumerable risk factors, and they can also be induced by various mechanisms and direct or indirect acts of the medication used.
Falls have a great impact on aging due to high morbidity and high personal, social and eco-nomic costs resulting from the damage caused. Falls emphasize the senescence process leading to an important loss of autonomy and quality of life among the elderly, and it can also have repercus-sions among the caregivers who are encouraged to provide special care to the family member, adapt-ing their whole routine accordadapt-ing to recovery or adaptation after falls.3
Approximately 28% to 35% of people over 65 suffer falls each year, and this proportion rises to 32% to 42% in the elderly over 70 years old. However, some literature reviews show that the incidence of falls in a household population aged over 70 can reach up to 49%. In the year 2000, Brazil ranked third in deaths related to external causes among elderly people living in the State of São Paulo, registering 2,030 deaths related to falls in the age group of 60 or older. Falls ranked irst among the causes of death in this group, being responsible for 1,328 cases and representing 31.8% of the total.4
Despite a clear relationship between falls and polypharmacy, studies have shown that the as-sociation is more signiicant with some drugs such as serotonin inhibitors, tricyclic antidepressants, neuroleptics, benzodiazepines, anticonvulsants, and class A antiarrhythmic medications. Each of these drugs has a previously studied coniguration regarding their expected adverse reactions, thereby requiring to be identiied for rational use. Iatrogenic occurrences due to medications may lead to loss of postural balance associated with the foreign envi-ronment in which the elderly are exposed to, leading to falls in this population.5
METHOD
This is a prospective study implementing an observational design, based on a clipping of the author’s master’s thesis dissertation. The sample consisted of 271 elderly individuals institutionalized for over six months in institutions of the Federal District, distributed into case and control groups. The case group consisted of 69 elderly individuals who presented the studied outcome of falls, from September/2013 to February/2014, and a control group consisting of 202 elderly people without records of falls in the same period.
The sample consisted of elderly residing in ive institutions of the Federal District of different administrative regions and with different types of management (private, philanthropic or philanthrop-ic-private) seeking equity in the sample.
Falls were considered as an unintentional event that resulted in the individual’s shifting their position to a level lower than their initial position.6
The terms polypharmacy and polypathology were classiied according to literature, correspond-ing to the use of more than ive daily medications and more than ive comorbidities diagnosed in the patient’s medical record, respectively.7
The primary database of the study was com-posed of information collected through a structured script. A data collection instrument was developed to evaluate the association between comorbidities and the use of medications with the occurrence of falls. Professionals who work and have experience in caring for the elderly participated in this evalu-ation stage. The instrument was initially applied to the irst ten seniors from the selected sample list, after which the instrument for data collection was adjusted (pilot test).
Two sets of exploratory variables were consid-ered: sociodemographic (gender, age, marital status, schooling) and health condition indicators (history of falls, comorbidities, functionality, mobility, use of medicines, self-perception about health).
Based on data collection, elderly with or without the record of falls were assessed for the presence of polypharmacy and polypathology. This assessment aimed to identify causal relationships between the variables.
A worksheet in Microsoft Access Program was used for data analysis and the statistical package Statistical Analysis (SAS) performed the inferential statistics. The information collected on the elderly was grouped according to the comparison groups. The association was made through the statistical
Odds Ratio (odds ratio), conidence interval and statistical p-value, based on the chi-square distribu-tion and logistic regression.
The Ethics Committee of the Faculty of Health Sciences of the University of Brasilia (Brazil) ap-proved the study under Process 285577 number 13. All subjects or legal guardians signed the Clear and Informed Consent Form.
RESULTS
A total of 271 elderly were considered eligible; of these, 202 had no records of falls and 69 had records of falls in the institutions. A total of 111 adverse events were identiied. The incidence of falls during the study was 41%.
Regarding the sociodemographic information, it was evidenced that the studied population had a mean age of 78 years, were predominantly female (57.5%) and there was a higher prevalence of singles or widowers - 40% were single and 43.7% were wid-owers. Moreover, 48.5% of the elderly were illiterate and only 27.82% completed the primary level of schooling. Low schooling had a close relationship with the participation of asylum activities, where 73.43% of those interviewed did not participate in reading activities. However, art activities and physi-cal activities were signiicant with adhesion of 69% and 46%, respectively.
Regarding indicators related to health condi-tion referring to the overall evaluacondi-tion of the elderly, most have a strong dependence for performing daily activities (53.1%), low scores in balance and gait evaluation (81.1%) and mental status evaluated as compromised (87.2%).
Self-perception about health is a variable con-sidered to be an important criterion of the elderly’s health condition and able to predict the survival of this population. We found that 46% of them consid-ered to be in good health, while 17.7% reported to be in poor health. Due to cognitive decline, 29.5% of the elderly were not able to respond.
Regarding comorbidities, the most frequent chronic-degenerative diseases identiied from the medical records were hypertension (77.4%), followed by diabetes (27.37%). Depression and dementia also presented high prevalence in the study with frequen-cies equivalent to 17.7% and 46.8%, respectively.
poly-pharmacy, where 69.7% of the elderly in the sample used ive or more medications. Antihypertensives (73.8%), sleep inducers (61.2%), diuretics (50.1%) and antidepressants (34.3%) were the most common.
Of the 69 elderly fall victims, we found that 100% of them used medication on a chronic basis.
Using inferential statistics shown in table 1, we found odds ratios (OR) of 1.61, with a conidence interval (CI) of 0.86 to 3.02 for the use of more than ive medications, characterizing a more severe poly-pharmacy. However, this variable had no statisti-cally signiicant relationship (p=0.141) with falls.
Table 1 - Association between polypathology and polypharmacy and the record of falls Brasília, DF, Brasil, September/2013 to February/2014. (n=271)
Risk factors Falls
n: 69 (%)
No falls
n: 202 (%) OR 95% CI p-value
Higher polypathology 19 (25.54%) 24 (11.88%)
2.82 1.43-5.56 0.0028
Lower polypathology 50 (72.4%) 178 (88.11%)
Higher polypharmacy 53 (76.81%) 136 (67.33%)
1.61 0.86-3.02 0.141
Lower polypharmacy 16 (23.18%) 66 (32.67%)
Table 2 and igure 1 show that polypathol-ogy had an increasing relationship with the risk of falls (statistically signiicant with p=0.04, as shown in Table 2), however the same did not occur in relation to polypharmacy (p=0.86, as
shown in Table 3). This shows that although both variables are closely related, they did not present the same association with falls, thus indicating signiicant differences, possibly due to confound-ing variables.
Table 2 - Association between falls and the number of pathologies. Brasília, DF, Brazil, September/2013 to February/2014
Polypathology
Number of morbidities Fall rate P-value trend
0 0.33
0.0465
1 0.17
2 0.17
3 0.23
4 0.27
5 0.46
6 0.40
7 0.57
Figure 1 shows the association of fall rates through OR and CI, and the number of comorbidi-ties detected in the elderly’s medical records. It is possible to observe an increasing and signiicant
0 1 2 3 4 5 6 7
0.
0
0.
2
0.
4
0.
6
0.
8
Polipatologia
%
Q
ue
da
Figure 1 - Association between falls and the number of comorbidities diagnosed in the elderly. Brasília, DF, Brazil, September/2013 to February/2014
In table 3, the causal relationship between polypharmacy and the increasing rate of falls was not identiied. Individuals with drug abuse (nine
or more medications) unusually had a lower rate of falls than elderly using three to nine medications, where p-value was not signiicant (p=0.8669).
Table 3 - Use of medications and risk of falling rate. Brasília, DF, Brazil, September/2013 to February/2014
Polypharmacy
Number of medications Fall rate p-value trend
Up to 2 medications 0.13
0.8696
From 3 to 5 medications 0.27
From 6 to 8 medications 0.32
From 9 to 11 medications 0.15
More than 12 medications 0.13
Figure 2 corroborates the data from table 3, in which there is an increasing relationship up to the use of six medications; however, when the elderly
2 4 6 8 10 12
0.
0
0.
1
0.
2
0.
3
0.
4
Polifarmácia
%
Q
ue
da
Figure 2 - Risk of falls rate and the number of medications used by the elderly. Brasília, DF, Brazil, September/2013 to February/2014
DISCUSSION
Associations between multiple disabilities, polypathology and polypharmacy are common in institutionalized elderly persons.2-3 Among the investigated morbidities in evaluating the institu-tionalized elderly population, diseases of the spine/ back (40%), hypertension (37.2%) and arthritis or rheumatism (32.1%) were the most common.1 In another investigation about the sociodemographic proile of the elderly assigned to a Basic Health Unit with a history of falls, chronic diseases with higher prevalence were related to systemic arterial hyper-tension, as cited by 63.3% of the elderly, as well as visual deicit (70%) and osteoarticular disease (62.7%).8 New evidence suggests a high incidence
of the elderly population in a number of comorbidi-ties, with 98.3% presenting from 4 to 7 morbidicomorbidi-ties, including vision problems (78.1%), back problems (63.3%), arterial hypertension (60.9%) and varicose veins (53.1%) being prominent.9
The present study conirms the high preva-lence of chronic degenerative diseases affecting the elderly, where hypertension (77.4%) followed by dementia (46.86%), diabetes Mellitus (27.3%) and cerebrovascular accident (CVA) (26.94%) stand out.
Several studies also include osteomuscular, genitourinary, psychiatric and sensorial diseases as factors that more often predispose elderly to the adverse event of falls.10 This fact conirms the impor-tance of evaluating comorbidities while reporting adverse events. The reality is that several patholo-gies increase the vulnerability of this population to falls even more, making the situation of the elderly even more unstable. The best interdisciplinary eval-uation is therefore essential, especially when faced with a prevalence where only 14% of the elderly interviewed are free of chronic diseases.11
low prevalence of pathologies, which can character-ize iatrogenesis from excessive drug consumption and the high medicalization of this age group.12
Prescribing medications for the purpose of correcting side effects from other previously administered agents is very common. This condi-tion, however, can lead to a chain of undesirable reactions known as cascade iatrogenesis.8,12 This characteristic of clinical practice may be related to the high prevalence of polypharmacy, which is not consistent with the presence of few pathologies. It is also possible to infer about the possible effect of the higher chronic disease incidence in the studied sample which require numerous drug treatments, thus leading to polypharmacy.
In this study, the evaluated elderly did not present more than ive pathologies, despite follow-ing the national trend related to an excessive use of medications (polypharmacy). However, inferential statistics have shown that multiple comorbidities are increasingly related to the occurrence of falls, a fact that does not occur with polypharmacy. The increasing associative relationship with falls when using two to six medications disappears when el-derly make use of more than six medications. This rejection of the alternative hypothesis possibly occurs due to the severity of functional dependence and cognitive decline presented by the elderly, where their using of more than ive medications was not a predictor for the increased risk of falls. This data is veriied through studies with elderly people living in long-term institutions in Germany, where a positive association between falls and partially dependent elderly was found; nevertheless, this relationship was not found between independent and the totally dependent elderly people. It is noteworthy that the group of partially dependent elderly demands more attention since their functional decline is not determi-nant for immobility, increasing the chance and risk of falls compared to those who are totally dependent.13
In order to reinforce evidence about the im-pact of polypathology on falls, a cross-sectional study of 4,050 British women aged 60 to 79 years showed that chronic diseases and multiple patholo-gies are more important predicting factors for falls than polypharmacy.14 The researchers ratiied the increase in the prevalence of the adverse event of “falls” in individuals affected by various chronic diseases, but the relation of falls with the number of drugs used by the elderly was not evidenced. In the same study, only hypnotics, anxiolytics and antidepressants showed signiicant associations for the increase in the number of falls.14
Contrary to the indings of the present study, other research has shown that the risk of falls sig-niicantly increases with the number of medications used daily by the elderly (p<0.0001).15 After
adjust-ing for the number of comorbidities and disabilities, polypharmacy remains a signiicant risk factor. This causal relationship is also demonstrated in other studies, showing that individuals using ive or more medications had a higher percentage frequency of falls than those who used fewer drugs. Apparently, the pharmaceutical classes more associated to the event were psychoactive and diuretic drugs.5,15
The growth in the number of elderly people who use some type of drug for chronic diseases and/ or to improve their quality of life increases every day. Several studies evaluating the use of drugs have shown that in addition to using a large number of pharmaceutical specialties among the elderly, there is a higher prevalence of the use of certain groups of drugs, such as analgesics, anti-inlammatories and psychotropic drugs.8 It was found that risk variables for falls and fracture in the elderly population are associated with medication use, since they cause drowsiness, alter balance, muscle tone and/or hypo-tension.16 Relevant indings in the literature on falls in the elderly have also showed statistically signiicant relationships (p=0.035) between falls and medication use by the elderly.17
Polypharmacy associated with inadequate prescription of medications is also related to the worse prognosis resulting from falls.18-19 Some au-thors have investigated the association between the use of medication and the occurrence of fracture due to falls by means of inferential statistics.20 In this study, the increase in the risk of fractures was 96% (OR:1.96, 1.16-3.30) of the cases among users of calcium channel blockers, and 109% in the elderly using bezodazepines (OR:2.09, 1.08-4.05).
The fact is that the worsening condition of the elderly population residing in long-term institutions is also linked to drug administration and the absence of continuous evaluation of these individuals. The elderly have peculiarities regarding medication use in relation to their functional reserves and physiological changes due to the aging process. Such peculiarities therefore greatly interfere in the pharmacokinetics and the medicinal properties of the drugs, which may lead to pharmacological effects such as an increase in adverse reactions.17,22 All of these changes that the elderly undergo in their clinical conditions and the concomitant use of medications stand out as factors that should be evaluated by the health team.23 In this context, this study ratiies the NANDA-I Taxonomy through the diagnosis of the risk of falls. Nurses evaluating the risk factors guarantees prevention of the adverse event of falls, and their evaluation should be used to develop care plans.
However, the present study has some limita-tions that could interfere with the obtained results such as possible memory bias due to implementing the recall method over the history of falls in the last six months. Other limiting factors are the absence of protocols for evaluating and notifying fall events in long-term institutions, leading to losses or under-reported incidence of the event in the institutions.
CONCLUSION
The main objective of the present study was to identify causal relationships involving falls in institutionalized elderly in relation to medication use and the presence of several comorbidities. Based on the research we can conclude that the use of ive or more drugs was not signiicant for falls, despite a high prevalence in the elderly studied, while being affected by numerous diseases implied in higher risk for the occurrence of falls in the elderly.
The process of determining causality of falls involves multiple factors. The presence of numerous comorbidities such as neurological diseases, demen-tia syndromes, cardiovascular and osteoarticular diseases lead to a reduction in physical capacity, and is linked to the inability of the static equilibrium, as conirmed in the present study associated with medication use.
Polypharmacy is another factor related to the event of falls. The proportion of elderly using inappropriate drugs is an important indicator of the quality of care. The use of multiple products, inap-propriate drug prescription for the elderly, the use of
two or more drugs with the same pharmacological activity and inadequate training of the health team favor the appearance of adverse effects and interac-tions, thereby causing cumulative toxicity, as well as reducing adherence to treatment and causing medication errors. Apart from these inadequacies, there are also assistance costs and repercussions resulting from medication use, such as developing and increasing the risk factor for falls.
Preventing falls and their resulting con-sequences is a major challenge, as developing measures necessary to control falls depends on the involvement of several agents. Due to its mul-tifactorial nature, preventive intervention should also be multidimensional involving well-trained professionals, including nurses who understand that the country is going through an aging process and that they need to be prepared to deal with new and old demands of this growing population. Therefore, health professionals should be trained and sensitized to the issue, equipped for evaluating and conducting interventions, and give special at-tention to elderly health promotion and education.
REFERENCES
1. Alvares LM, Lima RC, Silva RA. Ocorrência de
quedas em idosos residentes em instituições de longa permanência em Pelotas, Rio Grande do Sul,
Brasil. Cad. Saúde Pública. 2010; 26(1):31-40.
2. Gomes ECC, Marques APO, Leal MCC, Barros BP.
Fatores associados ao risco de quedas em idosos institucionalizados: uma revisão integrativa. Ciênc. saúde coletiva. 2014; 19(8):3543-51.
3. Bentes ACO, Pedroso JS, Maciel CAB. O idoso nas
instituições de longa permanência: uma revisão bibliográica.Aletheia. 2012; 38(39):196-205.
4. Gawryszewski VP. A importância das quedas no mesmo nível entre idosos no estado de São Paulo. Rev. Assoc. Med Bras. 2010; 56(2):162-7.
5. Rezende CP, Gaede C, Gonçalves MR, Oliveira EC. Queda entre idosos no Brasil e sua relação com o uso
de medicamentos: revisão sistemática. Cad. Saúde
Pública. 2012; 28(12): 2223-35.
6. Organização Mundial da Saúde. Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde – CID-10. [2014 Jul 13]. Disponível em: http://www.datasus.gov.br/cid10/ v2008/cid10.htm
7. John CW, Kathriyn JR, Richardson MS, Carlo AM,
Mathew OW, Pharm PD. Meta-analysis of the Impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009; 169(21):1952-60.
8. Santos RKM, Maciel ACC, Britto, HMJS, Lima JCC,
risk of falls among the elderly registred in a primary
healthcare unit of the city of Natal in the state of Rio Grande do Norte, Brasil. Ciência saúde coletiva. 2015; 20(12):3753-62.
9. Tavares DMS and Dias FA. Functional capactiy, morbidities and quality of life of the elderly. Texto contexto - enferm. 2012; 21(1):112-20.
10. Abreu HCA, Reiners AAO, Azevedo RCS, Silva AMC, Abreu DROM, Oliveira AD. Incidência e fatores preditores de quedas de idosos hospitalizados. Rev. Saúde Pública. 2015; 49:37.
11. Valentin FCV, Fonseca MCR, Santos MO, Santos
BMO. Avaliação do equilíbrio postural e dos fatores ambientais relacionados às quedas em idosos de instituições de longa permanência. Estudos Interdisciplinares sobre o Envelhecimento. 2013; 14(2):207-24.
12. Gonzalez RP, Castillo PV, Hernández SG, Quintana
GE, Gutiérrez GM. Polifarmacia en el adulto mayor: ¿es posible su prevención? Rev Ciencias Médicas. 2014; 18(5):791-801.
13. Kron M, Loy S, Sturm E. Risk indicators for falls in
institutionalized frail elderly. Am J Epidemiol. 2003; 158(1):645-53.
14. Lawlor DA, Patel R. Association between falls in
elderly women and chronic desease and drug use:
cross sectional study. BMJ. 2003; 327(7417):712-7. 15. Zeire JP, Dieleman A, Hofman HAP, Pols TJM, Van
Der Cammen BH. Polypharmacy and falls in the middle age and elderly population. British Journal of Clinical Pharmacology. 2005; 61(2):218-23.
16. Hamra A, Ribeiro MB, Domingues OF. Correlação entre fratura por queda em idosos e uso prévio de medicamentos. Acta Ortop. Bras. 2007; 15(3):143-5.
17. Lojudice DC, Laprega MR, Rodrigues RAP. Queda
de idosos institucionalizados: ocorrência e fatores associados. Rev Bras Geriatria Gerontologia. 2010; 13(3):403-12.
18. Del Duca GF, Ante DL, Hallal PC. Quedas e fraturas entre residentes de instituições de longa permanência para idosos. Rev. Brasileira de Epidemiologia. 2013; 16(1):68-76.
19. Manso MEG, Biffi ECA, Gerardi TJ. Prescrição inadequada de medicamentos a idosos portadores de doenças crônicas em um plano de saúde no município de São Paulo, Brasil. Rev Bras Geriatr Gerontol. 2015; 18(1):151-64
20. Coutinho ESF, Flecher A, Block KV, Rodrigues LC. Risk factors for falls with severe fracture in elderly
people living in a middle-income country: a case
control study. BMC Geriatrics. 2008; 8(1):1-7.
21. Lucchetti G, Granero AL, Pires SL, G1orzoni
ML. Fatores associados a polifarmácia em idosos institucionalizados. Rev Bras Geriatria Gerontologia. 2010; 13(1):51-8.
22. Secoli SR. Polifarmácia: interações e reações adversas
no uso de medicamentos por idosos. Rev Bras Enferm. 2010; 63(1):136-40.
23. Martins GA, Acurcio FA, Franceschini SCC, Priore
SE, Ribeiro EQ. Uso de medicamentos potencialmente inadequados entre idosos do município de Viçosa, Minas Gerais, Brasil: um inquérito de base populacional. Cad Saúde Pública. 2015; 31(11):2401-12.
Correspondence: Karine Marques Costa dos Reis Address: AOS 07, Bloco A, ap. 102,
Octogonal – Brasília, DF, Brasil E-mail: karinreisdf@hotmail.com
